Contents

Abstract

The world's highest HIV prevalence and the increasing number of deaths
due to AIDS is having unprecedented impact on Swaziland. Worryingly,
with a generation of orphans and rapidly escalating poverty, this
desperate situation is being accepted as 'normal'. HIV/AIDS in
Swaziland has been characterized by a slow onset of impacts that have
failed to command an emergency response. With insufficient resource
allocation and a lack of capacity, slow onset events can become
emergencies. The absence of an agreed definition of \"disaster\" or
\"emergency\" has helped to sustain this characterisation. The nature of
these terms is changing. The case of Swaziland emphasizes that they can
be long-term, complex, widespread events that evolve over years.

Swaziland is experiencing a generalized epidemic. National sero-sentinel
surveillance prevalence increased from 3.9% in 1992 to 42.6% in 2004
(MOHSW, 2006). HIV prevalence is estimated at 19% among the entire
population and 26% among productive adults (CSO, 2007). Currently, there
are around 220,000 people living with HIV. At similar prevalence rates,
this would equate to 56 million and 92 million infected individuals in
the USA and EU respectively. Prevalence is similar in rural and urban
areas, and all districts. Unless the trajectory changes, AIDS may claim
the lives of two thirds of all 15 year olds (UNAIDS, 2000).

HIV/AIDS is different from past diseases. Previous epidemics were
short-term and worked their way through society or were treated and
eliminated. HIV/AIDS is a long-term event. Rising HIV prevalence
predates intensified impact. The multidimensional impact of infections
will last generations. Negative effects on families become embedded
within Swazi society, altering the future development path of the
country. Although dramatic, the estimates cited in this paper are
conservative. Effective interventions will require an emergency response
aimed at building capacity for long-term programmes founded on the
realities driving Swazilandís epidemic.

HIV/AIDS is permanently altering the structure of Swazi society. By 2025
there will be a thinning of the older age groups and the very young.
Deaths among productive age groups are increasing the dependency ratio,
constraining coping mechanisms and economic growth. Life expectancy fell
from 60 years in 1997 to 31.3 years in 2004 - the worldís lowest.
Mortality has risen significantly across the entire population over the
past fifteen years. Infant mortality increased from 79 per 1,000 births
in 1992 to 108 in 2004. Maternal mortality has increased from 230 per
100,000 births in 2000 to 370 in 2004. The crude death rate has doubled
from 11 deaths per 1,000 people in the early 1990ís to 21.2 in 2004.
Recent analysis show deaths rates in all regions in Swaziland now exceed
emergency thresholds.

HIV/AIDS is negatively impacting Swaziland's health systems, as rising
morbidity increases the patient loads at all levels. While demand for
services increase, there is a parallel reduction in the capacity to
supply them. Rising TB prevalence is compounding this public health
disaster. The provision of ART is placing significant strain on current
public health systems.

Hospitals are working beyond capacity. Since the late 1990s there has
been a rapid increase in the demand for beds. HIV/AIDS patients are more
susceptible to opportunistic infections, thus complicating medical
treatment they must receive. The demand for services over the next ten
years will grow. This increased demand will place additional strain on
staff, effectively crowding out other health and support services. This
will further foster demoralization among remaining staff and contribute
to the migration of health workers from Swaziland.

In addition, TB prevalence rose from 263 cases per 10,000 in 1990 to
1262 in 2005. Increases of this magnitude and a low treatment completion
rate raise the risk of MDR and XDR TB outbreaks. As TB can infect the
general population, it has the potential to turn the HIV epidemic into a
wider public health emergency.

ART roll-out could avert many deaths and reduce impacts across society.
Currently, only 28% of those in need are receiving treatment. More
resources dedicated to building capcity are required to ensure the
success of treatment programmes.

HIV affected households become further impoverished as income-earning
adults die. In 2001, 69% of the population - 80% in rural areas - were
living below the poverty line. It is likely that this has increased
further. Swaziland's Human Development Index (HDI) ranking has fallen
sharply since 2000, reflecting an overall fall in socio-economic
conditions. This is despite a per capita GDP ranking that is 3 times
higher than what is considered 'low human development'. The impact of
HIV/AIDS has reduced Swaziland's social indicators (for example: life
expectancy and crude death rate) to the point where the country is only
slightly above the lowest HDI category.

There are 130,000 orphans and vulnerable children (OVC) in Swaziland -
31.3% of all children. This number is projected to increase to 200,000
by 2010. The impact of this on community and household structures cannot
be overstated, as 43.4% of households are hosting orphans (Swazi VAC,
2006). At present, grandparents are masking the true extent of the
orphan problem. However, as these elder caregivers die, this vulnerable
population will be left without a support network. Inadequate
socialisation of a large group of orphans may result in the creation of
a dysfunctional generation of Swazi citizens. Increasingly, Swazi
society has come to see the OVC status of one-third of all children as
'normal'. This abnormal 'normality' is reflective of a desperate
society that has run out of options.

Swazi households are forced to use drastic coping strategies in order to
survive. The number of people reducing meal sizes fell between 2006 and
2007, but those not eating for an entire day or selling assets for food
increased. Households are no longer vulnerable to, but rather suffer
from, livelihood failure (Swazi VAC, 2004). In turn, this has created a
societal exhaustion that decreases individuals ability to care for those
in need or plan for the uncertainty of their future.

There has been a downturn in the Swazi economy over the past ten years.
A reduction in annual growth rates from 6% in the 1990's to a current
level of around 2% has resulted in negative per capita growth. The
average loss in GDP growth attributable to HIV/AIDS is around 1.6% per
year (Muwanga, 2004). However, this estimate is from the early 1990s
when prevalence rates had not reached the levels seen in the past four
years. Current figures may starkly highlight the negative impact of
HIV/AIDS on economic growth.

Swaziland has experienced a significant reduction in agricultural
production. Bad weather exacerbated by climate change is in part to
blame. The multi-dimensional impacts of HIV/AIDS are also responsible.
AIDS affected households experience a 54.2% reduction in maize
production and a 34.2% reduction in the area of land cultivated. The
national cattle population is estimated to have fallen by 11% between
2000 and 2002. Reductions in agricultural output and livestock ownership
have led to increasing vulnerability and food insecurity. In 2007, over
400,000 people in Swaziland required food aid - approximately 40% of the
entire population.

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